Where the Rubber Meets the Road

From San Francisco General Hospital

April 1997, Reviewed September 2008

When used correctly, latex and polyurethane condoms stop the spread of HIV almost 100% of the time. Condoms are like cars: If you have an accident with one, the cause is almost certainly operator error, not mechanical failure. The estimated failure rate of latex and polyurethane condoms is between 2% and 5% -- and when a condom does tear during sex, the break is usually the result of misuse, not a defect in the condom itself.

The Food and Drug Administration -- which considers condoms to be "medical devices," regulates their production, and makes frequent, unannounced inspections of condom-manufacturing plants -- has declared that the difference in quality between the best and worst condoms on the market "is tiny compared with the problems that users introduce."

Condoms are like cars in another respect: They work best when you follow the manufacturer's instructions. The most common cause of condom failure is a simple mistake, one that people make almost as soon as the condom is out of the wrapper: They place the rolled condom on the head of the penis upside down. In this position the condom looks like a mushroom cap, and it can be unrolled down the shaft of the penis only with difficulty.

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You may have to wedge your fingers between the condom and your penis to unroll it this way. The condom will still cover the penis, but because it is inside out, the ring at the base will usually be tangled, not snug and secure. This makes the condom more likely to slip off or tear during sex.

The rolled condom should be placed over the head of the penis the same way that a knit cap is placed on your head, with the rolled "brim" outside the cap, not tucked under. This way it rolls easily down the shaft of the erect penis. The condom ends up right-side out. The ring at bottom of the condom fits snugly at the base of the penis, and the condom stays in place during sex.

There's one more way in which a condom is like a car: You need to keep a condom well-lubricated. If you never change the oil in your car, the parts will grind against each other and break. A condom that is not kept lubricated is also much more likely to break -- but you should never use oil to lubricate a condom. Oil-based lubricants like Vaseline, cooking oil, Crisco, baby oil, suntan lotion, and most skin moisturizers will dissolve a latex condom, creating tiny holes. You can't see these holes, but they are there, and HIV can get through them.

For this reason you should always use water-based lubricants with condoms. And you should always use condoms made of latex or polyurethane, because non-latex condoms have pores that HIV can get through. Check the label. If the condom does not have the word LATEX or the word POLYURETHANE clearly printed on it, don't use it. And check the labels on all lubricants. Most lubricants designed specifically for sex -- brands like KY, ForPlay, and Astroglide -- are water-based, and the labels will clearly say so.

Many of these lubricants also contain an ingredient called nonoxynol-9 which may increase someone's risk of HIV. Using a lubricant that contains nonoxynol-9 without a condom will not prevent the transmission of HIV, and should be avoided because it could increase your risk of getting HIV.

Generously apply a water-based lubricant to your penis (or to the inside of the condom) before putting the condom on. (This allows the penis to move around slightly within the condom.) Once the condom is securely in place, rub lubricant on its outer surface, then apply more of the lubricant to your partner's vagina or anus. During sex, rub on more lubricant at frequent intervals. Keeping everything well-lubed cuts down on friction and puts less strain on the condom, making it even less likely that the condom will tear.

There is no such thing as a learner's permit for condom users, as there is for beginning drivers, and there are no mandatory driver- education programs for condom users either. That's too bad, because learning how to handle a condom with skill and confidence takes practice. Condoms do work. But they only work when they are used consistently and correctly.

Both women and men should study the following diagrams and instructions, and both should know that a newly developed "female condom," which is inserted directly into the vagina instead of placed on the penis, offers the same effective protection as a regular condom. Learning how to use condoms is like learning how to achieve sexual fulfillment. In both situations experience is the best teacher.

Correct Use of Condoms

Condoms Worn by Men

1. Always use a new latex or polyurethane condom each time you have vaginal or anal sex. (Condoms are also recommended for oral sex with a partner who is known to be, or is suspected to be, HIV-positive.) Open the package carefully, so that you do not tear the condom.

2. Place a few drops of water-based lubricant on the inside of the condom or on the penis itself.

3. Before any form of direct sexual contact with your partner, place the condom over the head of the erect penis, leaving about a half-inch of empty condom at the end (Figure 1). Note: On an uncircumcised penis, pull back the foreskin to expose the head of the penis before you place the condom over it.

4. Gently squeeze the tip of the condom to force out any trapped air. The condom should fit over the head of the penis like a small rubber cap, with the rolled "brim" outside the "cap" -- so that it will unroll easily down the shaft of the penis.

5. Hold the tip of the condom against the head of the penis and unroll the rest of the condom all the way down to the base of the penis (Figure 2). Rub water-based lubricant over the condom-covered penis and, for extra safety and comfort, apply additional lubricant to your partner's vagina or anus.

6. Slowly insert the covered penis into the vagina or anus. If at any point you feel the condom break -- or you even think it may be broken -- pull the penis out immediately. If broken, throw the condom away and use a new one.

7. After you ejaculate (cum), hold the condom to the base of the penis while pulling out of your partner. This keeps the condom from coming off while it is still in your partner's vagina, anus, or mouth. Gently peel the used condom off the tip of your penis (Figure 3) and throw it away. Never use a condom more than once.

Condoms Worn by Women

1. Carefully remove the female condom from its protective wrapper. Use a few drops of the lubricant that comes with the condom -- or any other water-based lubricant -- to make the outer surface of the condom moist and slick for easy insertion. Add extra lubricant, if desired, to the inner and outer rings of the condom (Figure 1) and to the vagina.

2. To insert the condom, a woman should squat down, lie back with her knees spread apart, or stand with one foot on a stool or low chair. Hold the condom with the open end hanging down. While holding the top ring -- the closed end of the condom -- squeeze the ring between your thumb and middle finger (Figure 2).

3. Now place your index finger between your thumb and middle fingers. Keep your fingers in this position, with the top of the condom squeezed in a flat oval. Use your other hand to spread the lips of your vagina (or have your partner do it) and insert the closed end of the pouch (Figure 3).

4. Once you have inserted the closed end of the condom, use your index finger to push the condom the rest of the way up into the vagina (Figure 4). Check to be certain that the closed end of the condom is up past the pubic bone -- a hard surface which can be felt by curving your index finger upward once it is a few inches inside your vagina. The female condom can be inserted up to eight hours before sex.

5. Make sure that the condom is not twisted inside the vagina. (It should be possible to move a lubricated finger well up inside the condom without encountering any sort of obstacle.) If the condom is twisted, remove it, add a drop or two of lubricant, and then reinsert it. Note: About one inch of the open end of the condom will hang outside the vagina.

6. Your partner should insert his penis directly into the condom. If at any point he inserts his penis underneath or alongside the condom, he should pull out immediately. Remove the condom, discard it, and use a new one. Note: Until you and your partner become familiar with the female condom, it will be helpful if one or both of you uses a hand to guide the penis into the condom.

7. After your partner ejaculates (cums) and pulls out, squeeze and twist the open end of the condom to keep the sperm inside. Pull the condom out gently. Discard it in a trash can, not in the toilet. Do not use the condom more than once. Never use both a male and a female condom at the same time -- the female condom will not stay in place and the extra friction will make the male condom more likely to break.

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